Mid-transverse Colon Research Articles

EP454 - Left Paraduodenal Hernia and Large Bowel Obstruction: A Case Report

Abstract Aims Internal hernias are uncommon and difficult to diagnose clinically. Of these, a paraduodenal hernia is the most common, but remains a rare condition. Cases reported in the literature are few and often describe small bowel obstruction as a result of small bowel herniation into the left paraduodenal space and lesser sac. Here we describe a case of left paraduodenal hernia resulting in large bowel obstruction. Method Written consent from the patient has been obtained to present the case and associated radiological and intra-operative images. A 50 year old male with no surgical history presented to the general surgical team via the emergency department with a 12 hour history of epigastric pain, vomiting, abdominal distension and 24 hours history of absolute constipation. CT showed a large bowel obstruction with a transition point in the mid transverse colon with a swirling of the mesentery and large bowel concerning for left paraduodenal hernia. Results Open laparotomy was the preferred approach. There was gross dilatation of the large bowel with a competent ileocaecal valve. The hepatic flexure was found herniating into the lesser sac under the ligament of Treitz. This was reduced and the large bowel decompressed via the appendix. The narrow based small bowel mesentery was expanded by dividing the mesenteric parietal peritoneum. The large defect was closed with interrupted non-absorbable sutures. The patient made an unremarkable post-operative recovery. Conclusion This is a rare pathology with interesting surgical anatomy and we present its radiological and intraoperative findings and operative management strategy.

EP552 - Colonoscope Incarceration in an Inguinal Hernia: A Case Report

Abstract Aim We report a rare case of incarceration of a colonoscope within left inguinal hernia, highlighting the unusual circumstances and challenges faced by colonoscopists. Case presentation An 83-year-old male patient with a known left inguinal hernia underwent an urgent colonoscopy for positive quantitative faecal immunochemical test, anaemia, weight loss and fatigue. The patient had declined any form of analgesia/sedation for colonoscopy. Scope guide was used during the procedure. Initially, a proximal sigmoid loop was negotiated successfully. The colonoscope reached the mid transverse colon but the procedure became uncomfortable for the patient. There was an obvious loop on the scope guide which could not be reduced despite various manoeuvres. An attempt to apply external pressure to allow progression revealed a large left inguinal hernia containing a loop of the colonoscope. Thus, it was decided to discontinue the procedure, however, unexpectedly, during withdrawal, the colonoscope became lodged. Attempts to manually reduce this were very uncomfortable for the patient, therefore, intravenous access was gained to administer sedation & analgesia. Another colleague was summoned to assist with manual reduction while simultaneously withdrawing the colonoscope allowing for reduction of the hernia and removal of the colonoscope. The patient was kept overnight for observations and was discharged home the following day. Subsequently CT colonography confirmed large left inguinal hernia containing sigmoid colon. Conclusion This case delves into the intricate details of the incident, exploring the contributing factors, such as the patient's medical history and the nature of the hernia. We discuss ways to avoid this complication in the future as well as suggest a technique for resolution of the complication.

Acute superior mesenteric artery thrombosis in a 34-year-old male with thrombophilia: a case report

Introduction: Thrombophilic state, marked by extensive formation of blood clots within the vascular system poses a formidable peril, leading to loss of circulatory integrity and systemic well-being. Superior mesenteric artery (SMA) thrombosis is a serious medical disorder characterized by the obstruction of the arterial blood flow to the gastrointestinal tract, which is associated with significant morbidity and mortality. The condition has a plethora of etiological causes. Vague abdominal pain is a common clinical manifestation, and there is a very high mortality rate.Case Presentation: A 34-year-old Pakistani male presented with rapidly worsening acute abdominal pain over a 10-hour period. Clinical examination revealed elevated blood pressure, while other vital signs remained within normal limits. Abdominal examination findings were inconclusive compared to the patient's severe abdominal pain complaint. Contrast-enhanced CT scan indicated a large thrombus in the superior mesenteric artery with radiological features suggestive of intestinal ischemia, extending from the duodeno-jejunal flexure to the mid-transverse colon. Subsequently, the patient underwent exploratory laparotomy with extensive bowel resection and received anticoagulant therapy. He subsequently experienced compensated right lower limb ischemia, treated conservatively with high-dose anticoagulant therapy. Within days, bowel anastomotic leak developed, requiring multiple surgeries. Eventually, the patient progressed to septic shock, followed by multiorgan failure, culminating in a fatal cardiac arrest.Conclusion: Acute mesenteric ischemia, a rare abdominal emergency with an incidence of 6 per 100,000, is associated with a substantial mortality rate, ranging from 58% to 93% among diagnosed cases. The challenges posed by SMA thrombosis include diagnostic complexities, as it frequently manifests with symptoms disproportionate to clinical signs, and results in catastrophic complications, necessitating high suspicion index and prompt intervention.

Intestinal nontuberculous mycobacteria infection: A case report.

Intestinal nontuberculous mycobacteriosis due to nontuberculous mycobacteria infection has clinical manifestations similar to intestinal tuberculosis and inflammatory bowel disease, causing difficulties in clinical diagnosis. A 42-year-old male patient was admitted to the Sino-Japanese Friendship Hospital of Jilin University in June 2021 for diarrhea and intermittent hematochezia since April 2021. He was diagnosed with inflammatory intestinal disease by colonoscopy and midtransverse colon biopsy. However, the symptoms did not relieve after 2 months of mesalazine treatment. In August 2021, the patient was admitted to the outpatient department for suspected "intestinal tuberculosis." A diagnosis of intestinal nontuberculous mycobacteriosis was confirmed based on pathology and nucleotide-based matrix-assisted laser desorption/ionization time of flight mass spectrometry (MALDI-TOF MS). After 2 weeks of antimycobacterial therapy, the patient's diarrhea was relieved, and hematochezia no longer appeared. In November 2021, recolonoscopy revealed scattered erosions and ulcers in ileocecal valve and ascending colon, while both nucleotide-based MALDI-TOF MS and next-generation sequencing could still detect Mycobacterium intracellulare. This study reported a patient with an intestinal nontuberculous mycobacteriosis diagnosed by colonoscopy biopsy and nucleotide-based MALDI-TOF MS, and symptoms were relieved after antimycobacterial treatment.

Tubular colonic duplication: a case report and brief review of the literature

BackgroundThe occurrence of complete tubular colonic duplication is exceedingly rare. In most cases, resection of the duplicated colon may not be possible because of common blood supply with a single mesentery shared between the duplication and associated original bowel (Karkera et al., Pediatr Gastroenterol Hepatol Nutr 18:197-201, 2015).Case presentationIn this paper, we present a case of a 9-month-old girl who was noticed to pass stools through her vagina since birth despite normal anus in place, in association with constipation and pain on defecation. On local examination, a vestibular fistula was found. Further management including fistulogram, barium enema, and laparoscopy were performed. She was found to have tubular T-shaped colonic duplication with separate lumens from the mid-transverse colon downwards. Due to a shared fused wall, a decision was made to create a side-to-side (window) anastomosis at descending colon level using GIA staplers and end-to-side anastomosis at a sigmoid level between duplicated and normal colons with (mucosectomy) of duplicated colon down to the perineum.ConclusionsTubular colonic duplication should be kept in mind in patients presenting with vestibular fistula and fecal soiling in the presence of a normal anus. Minimal-invasive procedures are a safe and good alternative.

545 Optimal Surgical Approach for Mid-Transverse Colon Cancer; a Systematic Review and Meta-Analysis

Abstract Background and Aim The incidence of cancer colon below the age of 50 has increased dramatically. in addition, the database lacks a review to analyze the outcomes of surgeries for mid-transverse colon cancer with several recent controversial studies. Our aim was to compare the outcomes of extended hemicolectomy versus transverse colectomy for mid-transverse colon cancer. Method PubMed, Scopes, Web of Science and Cochrane library were searched for eligible studies from inception to 1 May 2022 and a systematic review and meta-analysis were done to detect Results according to eligibility criteria 8 studies (2237 patients) were included in our study. The pooled results of the included studies showed no difference in the 5-year OS, 3-year DFS and 5-year DFS between the two types of surgery (5-year OS, RR = 1.15, 95% CI = 0.94-1.39, P = 0.17), (3-year OS, RR = 0.96, 95% CI = 0.88-1.06, P = 0.42) and (5-year DFS, RR = 1.21, 95% CI = 0.91-1.62, P = 0.20). In addition to that, the recurrence rate and the incidence of complications were similar in the two groups (Recurrence rate, RR = 1.08, 95% CI = 0.62-1.89, P = 0.79) and (Complications, RR = 1.07, 95% CI = 0.74-1.54, P = 0.72). however, the number of LN harvest and the time of the operation was more in case of extended hemicolectomy. Conclusions Despite harvesting less LN, transverse colectomy has similar oncological outcomes to extended hemicolectomy for mid-transverse colon cancer. Moreover, no significant difference in the incidence of complications.

Simultaneous colonic metastasis of advanced gastric cancer: a case report

BackgroundAlthough distant metastasis in gastric cancer can be present at the time of the initial diagnosis, colonic metastasis is extremely rare. This report describes a case of simultaneous colonic metastasis of advanced gastric cancer.Case presentationThe patient was a 78-year-old woman with nausea and epigastric pain. Upper gastrointestinal endoscopy revealed an advanced invasive ulcerative tumor in the lesser curvature of the stomach extending from the anterior to the middle portion. Colonoscopy revealed a 4-mm polyp-like lesion in the mid-transverse colon; therefore, a polypectomy was performed. Both gastric and colonic tumors showed poorly differentiated adenocarcinoma with signet ring cell carcinoma. After providing informed consent, the patient underwent a total gastrectomy. Histologic examination showed similar morphologic features of both gastric and colonic tumors. Immunohistochemistry staining showed that these tumor cells were positive for cytokeratin (CK) 7 and negative for CK20.ConclusionsThis was an extremely rare case of simultaneous colonic metastasis of advanced gastric cancer. Because missed metastasis can result in a poorer prognosis, we propose a systemic search including colonoscopy for patients with advanced gastric cancer, especially cases involving poorly differentiated adenocarcinoma or signet ring cell carcinoma.

Comparing the techniques and outcomes of laparoscopic transverse colectomy to laparoscopic hemicolectomy in mid-transverse colon cancer resection.

The mid-transverse colon cancer is relatively uncommon in all colon cancers and the optimal surgical approach of mid-transverse colon cancer remains debatable. Our study aimed to depict the techniques and outcomes of laparoscopic transverse colectomy in one single clinical center and compare this surgical approach to traditional laparoscopic right hemicolectomy and laparoscopic left hemicolectomy. This was a retrospective cohort study of patients with mid-transverse colon cancer in one single clinical center from February 2012 to October 2020. The enrolled patients were divided into two groups undergoing laparoscopic transverse colectomy and laparoscopic right/left hemicolectomy, respectively. The intraoperative, postoperative complications, oncological outcomes and functional outcomes were compared between the two groups. The primary endpoint was disease free survival (DFS). The study enrolled 70 patients with 40 patients undergoing laparoscopic transverse colectomy and 30 patients undergoing laparoscopic hemicolectomy. The intraoperative accidental hemorrhage and multiple organ resection occurred similarly in the two groups. In transverse colectomy, caudal-to-cephalic approach was likely to harvest more lymph nodes although require more operation time than cephalic-to-caudal approach (23.1 ± 14.3 vs. 13.4 ± 5.4 lymph nodes, P = 0.004; 184.3 ± 37.1 min vs. 146.3 ± 44.4 min, P = 0.012). The laparoscopic transverse colectomy was marginally associated with lower incidence of overall postoperative complications and shorter postoperative hospital stay although without statistical significance (8(20.0%) vs. 12(40.0%), P = 0.067; 7(5-12) vs. 7(5-18), P = 0.060). The 3-year DFS showed no significant difference (3-year DFS 89.7% in transverse colectomy vs. 89.9% in hemicolectomy, P = 0.688) between the two groups. The alternating consistency of defecation occurred significantly less after laparoscopic transverse colectomy than laparoscopic hemicolectomy (15(51.7%) vs. 20(80.0%), P = 0.030). The laparoscopic transverse colectomy is technically feasible with satisfactory oncological and functional outcomes for mid-transverse colon cancer. Performing the caudal-to-cephalic approach might be more advantageous in lymphadenectomy.

S2741 Ischemic Colitis Imitating Inflammatory Bowel Disease

Introduction: Inflammatory bowel disease (IBD) and ischemic colitis (IC) are two different entities that can present similarly. There have been case reports of Crohn’s disease mimicking IC in elderly population. In contrast, we present a case of a young patient whose clinical history was consistent with IBD, but he was ultimately found to have IC on biopsy results. Case Description/Methods: A 36-year-old male with a history of type I diabetes mellitus, hypothyroidism as well as family history significant for IBD presented with abdominal pain, nausea, emesis, and diarrhea. In the emergency room, he was afebrile and hemodynamically stable with BP of 121/88 mmHg and HR of 90 BPM. Labs were significant for mild leukocytosis and normal lipase. Computed tomography of abdomen pelvis with contrast revealed diffuse colonic thickening concerning for acute colitis. C. difficile and gastrointestinal pathogen panel were negative. The day after admission, he was found to have intermittent episode of hematochezia along with elevated fecal calprotectin and c-reactive protein at 2945 ug/g and 38 MG/L respectively. Patient’s elevated inflammatory marker in setting of negative infectious work up, family, and personal history of autoimmune diseases were concerning for IBD. Patient underwent colonoscopy which revealed large ulcerated, edematous, and erythematous area in the mid-distal proximal transverse colon (50-80cm from the anal verge) (Figure) with rest of colonic mucosa and terminal ileum appearing normal. Biopsies from the mid transverse colon showed paucicellular lamina propria with edema, hyalinization, vascular dilation, and congestion consistent with ischemic colitis without any significant crypt architectural distortion, basilar lymphoplasmacytosis or evidence of metaplasia. Precipitant for ischemic colitis was unclear in this patient. He was treated symptomatically for ischemic colitis and had symptomatic improvement at time of discharge. Discussion: It is essential to consider IC in a young patient with family and personal history of autoimmune disease presenting with signs and symptoms typical for IBD as IC can mimic IBD. Timely and proper diagnosis is necessary as treatment for these two disorders is completely different. IBD can require medications like biologics which may have dangerous side effects if used inappropriately where IC is managed symptomatically.Figure 1.: Colonoscopy showing large edematous and erythematous area in the mid-distal proximal transverse colon.

Laparoscopic transverse colectomy with complete mobilization of right-sided mesocolon and ileocecum preservation for mid-transverse colon cancer.

Laparoscopic transverse colectomy with complete mobilization of right-sided mesocolon and ileocecum preservation for mid-transverse colon cancer.

Laparoscopic extended right hemicolectomy versus laparoscopic transverse colectomy for mid-transverse colon cancer: a multicenter retrospective study from Kanagawa Yokohama Colorectal Cancer (KYCC) study group.

The laparoscopic surgery approach for mid-transverse colon cancer (MTC) varies depending on tumor characteristics and the guidelines implemented by each surgeon; the optimal surgical procedure for MTC has not been established. This study aimed to compare the surgical outcomes of laparoscopic extended right hemicolectomy (Lap-ERHC) and laparoscopic transverse colectomy (Lap-TC) for MTC. This was a multicenter, retrospective study. We surveyed eight hospitals, by questionnaire, on MTC surgery policies and retrospectively compared the short- and long-term surgical outcomes for patients with MTC who underwent Lap-ERHC or Lap-TC between January 2008 and December 2019. A total of 129 patients were enrolled, of whom 35 underwent Lap-ERHC and 94 underwent Lap-TC. There were no significant differences in tumor progression between the two groups. Operation time was significantly longer (202min vs. 185min, p = 0.026). We observed a higher complication rate (≥ grade 3) in the Lap-ERHC group than in the Lap-TC group (11.4% vs. 3.2%, p = 0.086). Three patients (8.6%) who underwent Lap-ERHC developed anastomotic leakage; none of the patients who underwent Lap-TC had this complication (p = 0.018). The 3-year overall survival rates (stage I: 100% vs. 91.9%, p = 0.64; stage II: 100% vs. 95.5%, p = 0.46; stage III: 100% vs. 88.2%, p = 0.91, respectively) were similar between the two groups. Lap-ERHC for MTC has the same long-term outcomes as Lap-TC. However, Lap-ERHC for MTC has a higher complication rate. Therefore, Lap-TC may be recommended for patients with MTC. UMIN000042674.

A126 ONCE IS BY CHANCE, TWO IS A TREND: A RECURRING FINDING WITHIN THE POST-RESECTION DEFECT

Abstract Background A 74-year-old male was referred for the management of a large non-pedunculated colorectal polyp in the transverse colon. On optical evaluation, including high-definition white-light and narrow-band imaging (NBI), a 30mm 0-IIA non-granular large non-pedunculated colorectal polyps (LNPCP) was identified with optical features in keeping with adenomatous histopathology (NBI International Colorectal Endoscopic II, Japan NBI Expert Team IIA, Kudo Pit Pattern III/IV). Endoscopic mucosal resection (EMR) was performed. During sequential tissue transection and evaluation of the expanding submucosal defect a hole with a surrounding white-cautery ring was identified in keeping with significant deep mural injury. However, on careful evaluation a cystic structure was identified with a viscous amorphous substance emanating from it. Endoscopic resection of the lesion was completed with subsequent through-the-scope mechanical clip closure of the area of concern. Aims case report showing unique finding of intra-cellular mucin emanating from the post-resection defect has been identified as a potential intra-procedural finding of a mucinous adenocarcinoma Methods Endoscopic mucosal resection of a mid transverse colon polyp Results Histopathology identified a villous adenoma with high-grade dysplasia with submucosal mucin and an indeterminate focus of carcinoma; highly suspicious for a mucinous adenocarcinoma. No muscularis propria was identified. After multi-disciplinary review, the patient underwent laparoscopic right hemicolectomy with no evidence of invasive disease. Conclusions Recently coined as the “fish-eye” polypectomy defect, intra-cellular mucin emanating from the post-resection defect has been identified as a potential intra-procedural finding of a mucinous adenocarcinoma; specifically, in an otherwise benign appearing LNPCP based on real-time optical evaluation. Herein we describe the second case in the literature. This reinforces the importance of meticulous evaluation of the post-resection defect to stratify this finding from deep mural injury. Moreover, further understanding of the clinical ramifications of this unique intra-procedural finding is needed. Funding Agencies None

Laparoscopic transverse colectomy with extended complete mesocolic excision for mid-transverse colon cancer.

Laparoscopic transverse colectomy with extended complete mesocolic excision for mid-transverse colon cancer.

Feasibility of Indocyanine Green Fluorescence Lymph Node Mapping for Radical Colectomy of Mid-Transverse and Left-Sided Colon Cancer

Feasibility of Indocyanine Green Fluorescence Lymph Node Mapping for Radical Colectomy of Mid-Transverse and Left-Sided Colon Cancer

Self-inflicted stab injury with abdominal evisceration: A case report

Introduction and importanceSelf-inflicted abdominal stab injury with an intention of self-harm is uncommon. Moreover, self-inflicted injury leading to avulsion of the colon has rarely been reported in the literature. We report a case of a 42-years-female with schizoaffective disorder who presented with self-inflicted stab injury on the abdomen resulting in abdominal evisceration.Presentation of caseA 42-years-female with schizoaffective disorder (F25) for 10 years presented to the emergency department with multiple, self-inflicted injuries on the abdomen. A large free portion of the omentum and segment of the bowel were brought in a plastic carry bag. Examination revealed multiple transverse hesitation cuts in the epigastrium and a single deep penetrating transverse cut resulting in the evisceration of the omentum and colon. Intra-operatively, avulsion of a large portion of the greater omentum and missing segment of the mid transverse colon was observed. The patient underwent an immediate abdominal exploration and side-to-side colo-colic anastomosis along with diversion ileostomy. At three months following primary surgery, ileostomy closure was done.ConclusionPatients with schizophrenia spectrum psychosis are at risk of self-harm and in our case a schizoaffective patient presented with self-inflicted injuries that required an emergency abdominal exploration and repair. This case highlights a multi-disciplinary approach for the management of these cases and mandates clinicians and caregivers to be more vigilant to restrict injuries in the future.

S1713 Surgical Mesh Protrusion Through the Transverse Colon Masquerading as a Colonic Mass

Introduction: The differential diagnosis for abdominal pain in the setting of prior abdominal surgery is vast. Within general surgery, hernia repair is a frequently performed procedure and use of mesh has been shown to reduce the overall rate of recurrence. Unfortunately, mesh implantation is associated with many potential complications and risks. Having a high index of suspicion for the proper differential diagnosis is critical, so diagnosis is not delayed and the appropriate management can be started. We present the case of a female patient who presented with epigastric pain and was found to have surgical mesh from prior hernia repair perforating through the colon. Case Description/Methods: This is a 52 y/o female with PMH of pancreatic cancer, s/p Whipple procedure and abdominal hernia s/p repair presenting with complaints of dull epigastric pain exacerbated by eating and relieved by rest. She endorsed constipation but denied any fever, nausea, vomiting, diarrhea, melena or hematochezia. Physical exam was notable for moderate generalized pain and guarding, but no rebound tenderness. CMP revealed normal transaminases, mildly elevated Alk Phos 146 and normal T Bili 0.3 Rest of CMP and CBC were otherwise unremarkable. CT Abd/Pelv w/contrast revealed masslike diverticulitis in the mid-transverse colon concerning for a mass. Given these findings, colonoscopy was pursued which revealed nodularity, necrosis, irregular margins, and scarring in the mid-transverse colon compatible with protrusion of surgical mesh into the colon. Biopsies of this site were obtained, and pathology results were negative for malignancy. Patient has since been referred to surgery. Discussion: The differential diagnosis for abdominal pain is too numerous to count, and in the setting of prior abdominal surgery the task of obtaining the correct diagnosis is made even more difficult. Perforation of surgical mesh through the mid-transverse colon is an extremely rare phenomenon and the index of suspicion for such a complication must be high. In our case, though physical exam and laboratory studies were vague and nonspecific, CT Abd/Pelv findings increased our urgency for colonoscopy which resulted in subsequent appropriate referral and management of the patient. Unfortunately, literature search for abdominal pain in the setting of mesh protrusion through the colon has been heterogenous and scarce. Thus, more research must be done in this area.Figure 1.: Nodularity, necrosis, irregular margins, and scarring in the mid-transverse colon compatible with protrusion of surgical mesh into the colon.

Gastrointestinal Bleeds.

Gastrointestinal Bleeds.

S3131 An Unusual Case of Postprandial Diarrhea: Gastrocolic Fistula from Gastric Band Erosion

Introduction: Bariatric surgery is increasingly performed nowadays. Gastroenterologists may encounter patients with its complications. Known complication of laparoscopic adjustable gastric banding (LAGB) include reflux, band slippage, erosion, pouch enlargement, and port breakage. We report a case with an unusual complication of LAGB. Case Description/Methods: A 45-year-old male with LAGB and atrial fibrillation presented with chronic diarrhea. Symptoms onset was 3 years ago after his partial small bowel resection when he presented with peritonitis. The patient reported loose stool within 15 minutes after each meal, abdominal pain, and 13-lbs weight loss. Physical exam was unremarkable. Laboratory data were within normal limits except mild anemia (Hgb of 12.9 g/dL) and mild renal impairment (Cr of 1.55 mg/dL). Upper GI study with small bowel follow through showed two separate channels arising from the proximal stomach with one connecting to the mid-transverse colon, suggesting a gastrocolic fistula (GCF) (figure 1A). CT scan of chest/abdomen/pelvis that was performed prior to barium studies was reviewed and demonstrated gastric erosion of the LAGB, with tethering of gastric cardia to the transverse colon with prolapse of the tubing into the distal transverse colon (figure 1B). Subsequent upper endoscopy showed an eroded gastric band in the gastric cardia and appeared to be extending through the gastric wall (figure 1C). Colonoscopy noted gastric band was entering transverse colon and extended distally (figure 1D). Surgical specimen of previous small bowel resection was reviewed and didn't show small bowel ischemia nor small bowel Crohn’s disease. The patient is currently evaluated by a bariatric surgeon for the definite treatment. Discussion: GCF is an uncommon manifestation of certain malignancies, pancreatitis, Crohn’s disease, peptic ulcer disease, and few cases related to other bariatric surgeries, usually with sleeve gastrectomy. LAGB related erosions of stomach, colon, and small bowel have been reported. To best of our knowledge, there are only 3 other cases of GCF related to LAGB. We report a rare complication of LAGB. Mechanism of GCF from LAGB is not fully understood, and is likely related to erosion of gastric wall from band pressure or foreign body reaction. Symptoms includes abdominal pain, weight loss, diarrhea, and sepsis. Diagnosis is made with upper GI series, contrast enhanced CT and endoscopic visualization. Surgery is the mainstay of treatment with removal of band and closure of fistula.Figure 1.: Endoscopic image of gastric ulcer in first case (A). Microscopic image H&E stained 400x of lymphoepithelial lesion with surrounding lymphocyte mucosal invasion (B). Endoscopic image of polypoid lesion in second case (C). Microscopic image H&E stained 200x of diffuse lymphocyte invasion into the lamina propria and muscularis mucosa (D).

Perforated neonatal appendicitis: A rare presentation of Hirschsprung disease

Acute appendicitis is the most common diagnosis of an acute abdomen in children, however, it is extremely rare in neonates. Premature infants are more predisposed to the condition with increased rate of perforation causing peritonitis. The diagnosis is usually delayed and more often made during laparotomy or autopsy. Here, we report a baby girl with uneventful antenatal history was brought to the emergency department on day 15 of life with intestinal obstruction symptoms who was initially thought to have intussusception or small bowel volvulus. The infant was brought in for surgery and intraoperatively, a perforated appendix was found. Appendicectomy and peritoneal washout was performed. Post-operatively, the infant had persistent ileus and remain refractory to treatment with antibiotics and prokinetics. A re-laparotomy was done with colostomy and serial biopsies of large bowel. The histopathological examination of the biopsies could not exclude Hirschsprung disease. Then, rectal suction biopsy was performed prior to discharge and the acetylcholinesterase (ACH) enzyme study revealed a strong positivity for Hirschsprung disease. The infant subsequently underwent laparoscopic assisted transanal pull-through at 5 months old. The histopathological examination of the continuous section from anus to mid-transverse colon showed devoid of ganglion cells. In conclusion, neonatal appendicitis is a rare condition with atypical presentation and high rate of morbidity and mortality. It is paramount to have a high index of suspicion and it should be included in the differential diagnosis of an infant presenting with an acute abdomen with vague symptoms and signs.

A Rare Case of Pediatric Gastrointestinal Stromal Tumor

Aim: To discuss the management of rare pediatric tumor, Gastrointestinal Stromal Tumor (GIST)Methods: We report a case of 1 year old male child with transverse colonic GIST. Child presented with upper abdominal lump of one month duration with no other constitutional symptoms. On examination solitary intra-abdominal lump of size 10cm and 8cm, non tender, firm, freely mobile in the umbilical region was found. Contrast enhanced CT abdomen revealed 8.3cm and 6.2cm heterogenous enhancing mass at root of the mesentery. On exploration an exophytic pedunculated mass was arising from mid transverse colon, tumor excised along with 2 cm colonic margin. Counselling done as chemotherapy was not available in children. Child has been under regular followup for the last 18 months. Results: Histopathological examination revealed GIST with high mitotic index, immuno-histochemistry (IHE) markers CD117,CD34 and DOG 1 were positive.Conclusion: Pediatric GIST is very rare and there are no well established therapeutic guidelines for the management of pediatric GIST, so needs close long term followup after surgery and further guidelines need to be established.